HomeMy WebLinkAboutBuilding Permit # 5/12/2016 FORTH
BUILDING PERMIT � �� y�,:,. ._ '6
TOWN OF NORTH ANDOVER to
(l >� APPLICATION FOR PLAN EXAMINATION -
Permit NO: Date Received
n A�Rn7HD I`P�y^(5
Date Issued:
IMPORTANT:Applicant must complete all items on this page
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PROPERTY'owNER' ;. =
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it(lAP NO ' ,C PARCEL X170 ZONING;DISTRICT H�stor�c D�strtct yes
.: � Machine Shap Village yes. rt�...s;,
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building )2f-One family
❑ Addition ❑ Two or more family ❑ Industrial
❑ Alteration No. of units: ❑ Commercial
,KRepair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
Sep#ic ❑Well ❑Floadplain ❑Wetlands ❑„1NatersF ed District,
D Waterl,Sewer
Identification Please Type or Print Clearly)
OWNER: Name: ��o,� � �� Phone:
Address: Sl - l J -
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Supervisor's Construction License ` exp Dat65e
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Home;lrnprouement Lacense F Exp Date
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ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING ERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ (oFEE: $— � Idf- - '2- ::: 2---\
Check No.: � Receipt No.:��
NOTE: Persons contracting wi i u re stere ontractors do not have access the gu ty fund
Signature ofAgent/awner � .. S►gnsture of contractor'
5
NORTH
Town of
Andover
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No.
o L^KE ver, ass,
Ct-4 12. 2 1 io
q COC"1C"t WICK 1
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�.95 RATED P'V' 5
U BOARD OF HEALTH
Food/Kitchen
P R� T LD Septic System
THIS CERTIFIES THAT ... LiJV+..2*k.fi`&+a.... BUILDING INSPECTOR
has permission to erect .......................... buildings on �... .. . ' Foundation
Rough
tobe occupied as ...............E40.4 .......... ......... ......... .......................................................... Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS T Rough
Service
..............
..........................
BUILDING INSPECTOR Final
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approvedthe Building Inspector. Burner
Street No.
Smoke Det.
Estimate # 00073
Date: Mar 29, 2016
Jay Forst Roofing
500 Chesnut st
N Andover, Ma
jdog299msn.com
Status : Pending Accepted Date
Accepted By
r �MM€ -. .f"ll.:•J ,_,( ii; =;.
roofing removal -install 90 degree drip metal on all perimeter edges 1.00 $9;000.00 $9,000.00
-install ice Grace shield 6\\\\\\\'up from the drip edge
and along all eves.,3\\\\\\\of ice shield will also be
placed in each valley
-install synthetic underlayment on all surfaces not
covered by ice and water shield(synthetic
underlayment is stronger than standard felt
undedayment)
-install Architect shingles GAF HD or Certainteed
Landmark shingles using 6 nails per shingle for
increased resistance against shingle blow offs
-install hip and ridge
-flash all pipes with pipe flashings 18\\\\\\\"ice shield
will be installed on flashings.
flash metal flue pipes with steel pipe flashing
-install applicable ice shield and flashing against all
walls
-install valleys using cut or weave valleys
Subtotal : $9,000.00
Labor and material include
dunpester include Total $9,000.00
Phone:978-569-7135 1 Page 112
41
Estimate # 00073
Date:Mar 29,`2016.
Terms & COn"a f iris
Ja�Forst
Date: Date:
Phone:978-569-71351 Page 212
The Commonwealth of Massachusetts !?rinf Forrn
bepartinent of Industrial Accidents
Office of Investigations
r 600 Washington Street
Boston,MA 02111
www.naass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): �7�� %1`�s L LC—
Address: 7-/ IC-60 61 /20 n
City/State/Zip: 044 bon o 014- 61 F41 Phone#: � J
Are you an employer? Check the a propriate box: Type of project(required):
1.16-1 am a employer with 4. F-] I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g_ E]Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp.insurance comp.insurance.t
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.L5-Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13.❑ Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: �t%l2/t3NiP N1 fl w r4Y v!9t'� it�Vi LIENS
Policy#or Self-ins.Lic.#:--5 r I'I(f-61�5--I Expiration Date: It/I
Job Site Address: �;0'0 City/State/Zip: t13 nPi L �
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the/VlA for insurance coverage verification.
:l
I do hereby cender'Pe pains d pe alties of perjury that the information provided above is true and correct
Si afore: V � Date: ( t G
Phone#: 9 Z rZ
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
11/171207.:
CERTIFICATE OE LIABILITY INSURANCE
11 20 2015
THIS CERTIFECATE lS 165UF-o AS{ R 47TER OF 214FORTf1A:TiON ONLY AND CONFERS NO RIGW$ R1t7ON THE CERTIFICATE HoL.orzk THtS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY ANENr�.[-, EXTEND OR ALTER THE COVERAGE AFFORDED 9Y TijE POLICIES
sELJJw> TIIES pERTincATE OF INSURANCE DOES NOT CONZTITUTE A:C ON RACT SE714kq�EN THE ISSUING .944 RER(S), AUTTAGRI7.ED
R4;MSENTATIVE OR PRODUCeR,MOIRE CcRTIRCATE 14OLVER
IMPORTANT;If the cor6ficat bolder is an ADDTTION AL P4SURJE1Q,ttta poi cyjies)must 3sa codrartw-d-1f BU§kTION IS WXIGEIS,subject in
'l,tie tarms and coridit urtt of 11;*policy,cartain policlut mhy TegUire an en-dorsatnt~ttt.A St;iwmorrrk on thIr tuYlfficoto doim no't,cDuter tiigah taa'ti'na I.
cortificate Ii(Ador In lieu of su cT undrssavmenits.
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60brE-AGE,5 CERTIFICATE XW.18r-k, VISION PLUMBER-
THus IS 7C CEW IFY THAT THE PiOUGI-- OF INSURANCE I t$TED{YE W4 HXVE BEEN WI)ED-TO THE R EiJRE3 NAXI D AROVE TOR THE sPoUcY PERIOD
IComCATED. N{IT144'+HS+MMING ANY REQUIREmENT', TERM OR+:'An^,'.DMON OF ANY 00N-r R.AI�:Tj OR OTHER DOCUTAE14T WnT14 PZSPr-GT Tc->,rifl'31t;H THIS
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0ML'U'.MONS AND CONDMOMS CF SUCH POLICIES."1t;4.bI7''=i:�HGWtd MAY HAVE,MEN RED ICM VY PAID
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SHOULD LD ANY CW TAA;ASOLE OESCRORD POL ICIE5 SF CANCELLED BEFORE
THE fu'PtTJArON DATE s1il Y?<, NOTICE WILL Be DELIVERED M
city OfLexingUaniAbcARi7ATtGG°aP[i3 7IIEFOL3iY pr{7 54f F1 .
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Office of Consumer Affairs 8-.Business Regulation
01111E IMPROVEMENT CONTRAC FOR
egistrativrr- .9[f8�45 Typx
iration. Individual
RAYMOND A_M€PO L-
Rayinond MernH
16 THiSSII1 ST , . -
Dma#,MA 01826 Unci€rseeretary
kms.
Massachusetts -Department of Puoiic Said,
Board of Buildinu Regulations and Standards
Co'nstrucfio- 'i-ll .
I Jc-ens_: CS-05a795
Raymond A Me,, acM
i 16 Thissell Street Mlk:
Dracut MA 0182b
Expiration
Commissioner 05/29/2016
DEBRIS DISPOSAL AFFIDAVIT
In accordance with the provisions of M.G.L. c. 40, s. 54, Building Permit
# was issued with the condition that all debris resulting
from this work shall be disposed of in a properly licensed solid waste
disposal facility as defined by M.G.L c. 111, s 150A
The debris will be disposed of in:
Name of Waste Facility
5�// A,, —
Address of Waste Facility
111.5 Debris: As a condition of issuing a permit for the demolition, renovation,
rehabilitation or other alteration of a building or structure, M.G.L. c.40 S.54 requires
that the debris resulting therefrom shall be disposed of in a properly licensed solid waste
disposal facility as defined by M.G.L.c.111 s.150 A.Signature of the permit applicant,
date and number of the building permit to be issued shall be indicated on a form provided
by the Building Department and attached to the office copy of the building permit
retained by the Building Department.If the debris will not be disposed of as indicated,
the holder of the permit shall notify the building official,in writing,as to the location
where the debris will be disposed.
780 CMR—6`'Edition
Signature of Permit Applicant
Date